Contemporary Psychology: APA Review of Books
Eggshell Psyches, Crumbling Skulls, and Trauma
A review of
Psychological Injuries: Forensic
Assessment, Treatment, and Law
by William J. Koch, Kevin S. Douglas,
Tonia L. Nicholls, and Melanie L.
O'Neill
New York: Oxford University Press,
2006. 318 pp. ISBN 0-19-518828-4.
Reviewed by
Kathie Nichols
The experience of emotional injury has been a condition that has existed throughout history. The legal system has always acknowledged and accepted emotional injuries that stemmed from intentional torts such as battery. In 1948, the Restatement of Torts brought about compensation through the legal system for extreme behavior that caused deliberate infliction of emotional injury (Linden, 1997). The courts had more difficulty recognizing negligent infliction of emotional distress. It was not until 1970, in Rodrigues v. State, that negligent infliction of emotional distress became an independent tort and even then some type of physical injury was needed to allow a legal claim (Huffaker, 2001). Over time, the “zone of danger” concept allowed a person close enough to fear for their safety or witness death or mutilation to make claims of emotional injury. The traditional negligence principle of “foreseeability” has been applied to emotional trauma as well as physical injury. Courts still look at emotional claims for injuries with doubt and trepidation. Courts worry that the “floodgates” will be opened and everyone will want to be traumatized. Evaluation of these claims has become an area where psychology has played an essential role in sorting through these claims.
Post-traumatic stress disorder (PTSD) was added to the third edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1980). This diagnosis did much to influence the law and validate compensation for emotional injuries. Stone (1993) said, “No diagnosis in the American history of psychology has had more dramatic and pervasive impact on law and social policy than post-traumatic stress disorder” (p. 23). The diagnosis gave psychic harm a name and an objective criterion for a variety of civil claims for numerous types of severe emotional stressors. It helped the already shifting legal system legitimize psychological injuries. This was a large change. The legal system started with a skeptical view that required a physical injury for emotional damage and has evolved a system that accepts emotional trauma even with preexisting vulnerabilities. The law continues to struggle with the issue of causation, and it further struggles with issues regarding whether it is the sole cause of, or a contributing factor to, the emotional injury.
Emotionally injured people may have complex histories and preexisting mental conditions. The law, in its blunt and not always sensitive manner, labeled the issues that surround causation, contributing factors, and predisposition to psychological injury as the “thin skulls, crumbling skulls, and eggshell psyches” principles. “Thin and crumbling skulls” and “eggshell psyches” refer to previous psychological injuries and psychological vulnerabilities or predisposition to emotional trauma. In law, the “tortfeasors takes their victims as they find them” (Athey v. Leonati, 1996). In evaluation and treatment, the task is to sort through the history, personalities, and current mental state of the victims to help the legal system figure out the emotional impact a trauma may have had on a victim, then restore the victim to their previous level of emotional functioning.
As clinicians, we are all aware of the range of symptoms and severity that trauma causes. One person can be totally unaffected by the same trauma that leaves another person disabled. In fact, research indicates that 70 percent of the population is exposed at one time or another to traumatic events that can cause PTSD, yet only 8 to 9 percent are actually diagnosed with PTSD (Breslau, Davis, Andreski, & Peterson, 1991). That means that there are a lot of intervening factors that moderate or mediate trauma.
In Psychological Injuries: Forensic Assessment, Treatment, and Law, William J. Koch, Kevin S. Douglas, Tonia L. Nicholls, and Melanie L. O'Neill present an in-depth review of the interaction effects of social economic factors, gender, culture, and the type of stressors (e.g., witness, personal assault, natural disaster)—nowhere so carefully crafted and thoroughly researched as in this book. They review the research and statistics of trauma caused by motor vehicle accidents, assault, rape, natural disasters, workplace harassment, stalking, and bystander witness of traumatic events. The authors also review research on the interaction of the type of trauma with gender, race, culture, and preexisting conditions. Whether you are a clinician who assesses and treats traumatized clients or a forensic psychologist who evaluates clients for legal proceedings, this book will improve your knowledge and understanding, as well as of the integration of psychology and law. Assessment measures vary greatly across evaluations, as does the competence of evaluators. Treating clinicians and forensic evaluators, with their different roles, may view the same person very differently, depending on the measures they use, the history they gather, and the role they have. A treating clinician will probably not assess formally and take the client at his or her word, whereas a forensic evaluator will most likely use formal tests with reliability and validity and search for evidence of malingering and contributing factors with more diligence than the treating clinician. The authors provide an excellent review of research-based outcomes on structured and unstructured interviews and the various psychological tests used in assessing PTSD.
It was frustrating to read yet another “ideal world” litany of the assessment faults and shortcomings of psychologists in the legal arena, without reference to (a) the reality of managed care and the difficulty of getting insurance companies or clients to pay for any testing, much less the extensive list of tests needed to do a thorough assessment, and (b) the reality that one diagnostic session limits history gathering, testing, and the good assessment needed in such complex emotional injuries as PTSD. Rarely do clients come to therapy with a simple diagnosis of PTSD. These diagnoses are difficult to make, especially with victims with complex histories and preexisting conditions. Clients driven to therapy by the severity of their problems are usually wrought with anxiety and depression on top of their traumatic symptoms. Clinicians are given restrictive guidelines to treat within and are then criticized for the shortcomings of their evaluations. Insurance companies seem to want thorough assessments before they pay for emotional injuries but find thorough assessments unnecessary upon clinical presentation of the injuries. It would be nice to occasionally see critiques of this part of the system.
In recent years, critical incident debriefing has been lauded as the panacea for all disasters from hurricanes to school suicides. Research does not bear this out. In fact, much research shows poorer outcomes for those who receive treatment than hose who do not (Bisson, 2003; Ehlers & Clark, 2003). At best, outcomes are equal at the 4-month mark (Lee, Slade, & Lygo, 1996). The authors do a fantastic job with the review of the literature in this area as it relates to trauma and debriefing programs. These programs were adopted by well-meaning organizations, put into place, and not evaluated or examined again. Schools are the perfect example. The limited training of the counselors doing the debriefing and the secondary trauma that is sometimes caused by the process to students is abhorrent. Everyone should be aware of the research and poor or equal outcomes of this process. This book provides research across trauma type, gender, ethnicity, and comorbidity. The area of assessment and treatment of trauma in both psychology and law has changed greatly in the past 50 years. This book offers a complete view of psychological injuries, from both the legal and mental health viewpoints. It is full of research and statistics, some of which psychologists should collect for future reference. This book really pulls the literature together for the clinician or the attorney working in the area of trauma. It calls attention to the need for proper assessment and treatment from the field of psychology for the victims of trauma and acknowledgment of the reality of the devastation from emotional injuries of sometimes already fragile people. My clinical awareness and practice has been sharpened by its reading.
References
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author.
Athey C. Leonati, 3 S. C. R. 458 (1996).
Bisson, J. L. (2003). Single-session early psychological interventions following traumatic events. Clinical Psychology Review, 23, 481-499.
Breslau, N., Davis, G. C., Andreski, P., & Peterson,
E. L. (1991). Traumatic events and post-traumatic stress disorder in an urban population of young adults. Archives of General Psychiatry, 48, 216222.
Ehlers, A., & Clark, D. M. (2003). Early psychological interventions for adult survivors of trauma: A review. Biological Psychiatry, 53, 817-826.
Heinzerling, L. (2001). Tortious toxics. William and Mary Environmental Law and Policy Review, 26, 67-92.
Huffaker, M. L. (2001). Recover for infliction of emotional distress: A comment on the mental anguish accompanying such a claim in Alabama. Alabama Law Review, 52, 1003-1027.
Lee, C., Slade, P., & Lygo, V. (1996). The influence of psychological debriefing on emotional adaptation in women following early miscarriage: A preliminary study. British Journal of Medical Psychology, 69, 47-58.
Linden, A. M. (1997). Canadian tort law (6th ed). Vancouver, British Columbia, Canada: Butterworths.
Rodrigues v. State, 472 P.2d 509 (Hawaii 1970).
Stone, A. (1993). Post-traumatic stress disorder and the law: Critical review of the new frontier.
Bulletin of the American Academy of Psychiatry and the Law, 21, 23-36.
PsycCRITIQUES February 7, 2007 Vol. 52 (6), Article 4 1554-0138 © 2007 by the American Psychological Association
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